198603137-3-15-2024-31-AS-NMAN-D5XSUT-20240605141140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603137
Report Date: 03/08/2024
Date Signed: 03/15/2024 11:33:09 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240228160422

FACILITY NAME:	BURBANK SENIOR VILLA WEST		FACILITY NUMBER:	198603137
ADMINISTRATOR:	ZENOU, ADAM		FACILITY TYPE:	740
ADDRESS:	1911 GRISMER AVE		TELEPHONE:	(818) 295-2727
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	100	CENSUS: 91	DATE:	03/08/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Carmela Nieva, WC and Silvia Valdez ED		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not provide timely medical attention, which may have controbuted to death
Staff were unaware of resident’s POLST

INVESTIGATION FINDINGS:

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This is the amended copy of report previously issued to the facility.
At 9:45a.m. Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit and was greeted by the Wellness Coordinator(WC). At 10:40a.m. the Executive Director (ED) arrived to the facility and LPA explained the reason for the visit.
Prior to this visit on 02/27/24, LPA spoke with ED regarding the incident involving R1, at which time. LPA requested facility file of the resident #1 (R1), including physician report, need and service plan, hospice records and copies of an incident and death reports.
At the time of this visit LPA Alvizar- Ettima requested residents and staff roster and facility internal log/notes. At 10:30a.m LPA and Wellness Coordinator conducted a physical plant tour. At 10:50a.m. LPA obtained contact information of the nurses from the hospice company assisting R1. Between 11:00a.m. – 12:00p.m. LPA contacted via-phone Comfort Life Hospice and interviewed two (2) witnesses assisting R1. Between 2:00p.m.-2:30p.m. LPA interviewed facility staff #1 (S1). LPA asked questions relevant to the nature of the complaint.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240228160422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BURBANK SENIOR VILLA WEST	FACILITY NUMBER: 198603137
	VISIT DATE: 03/08/2024

NARRATIVE

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1.Staff did not provide timely medical attention, which may have contributed to death.

It was alleged that facility staff did not contact 911 within reasonable time. Interview of facility staff revealed that they had no knowledge that R1 needed medical attention due to Hospice nurse being present at R1’s bedside. S1 revealed that they had no knowledge that R1 required emergency medical attention. 911 was contacted by the hospice personnel that were present in R1’s room. Witness #2 (W2) indicated that witness #1 (W1) was present when R1 was taking they last breath. W1 indicated that they were present at the facility when R1 stopped breathing. W1 verified being in the room with R1 and did not notify facility staff that R1 needed medical attention. W1 indicated that R1 became unresponsive around 4:20p.m. W1 immediately contacted the hospice agency, then contacted 911 and conducted Cardiopulmonary Resuscitation (CPR) while they were waiting for Paramedics. W1’s response coincides with the information received from facility staff. A review of facility internal incident log/notes did not indicate any information to conclude that facility staff had knowledge that R1 needed medical attention. Overall investigation revealed that 911 call was made by W1 within less than 4 min. after resident became unresponsive.

Based on interviews and documents review there is an insufficient information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

2.) Staff were unaware of resident’s POLST.

It was alleged that facility did not honor R1’s Physician Order for Life-Sustaining Treatment (POLST) and no Cardiopulmonary Resuscitation (CPR) was provided to R1 after they became unresponsive. Staff revealed that Hospice nurse was present at the R1’s bedside when R1 was transitioning and became unresponsive. Hospice agency had a copy of R1’s Emergency Contact information as well as copy of POLST. Hospice personnel did not inform the facility staff that R1 required medical attention and became unresponsive. Therefore, they were unable to discuss R1’s POLST with the hospice personnel. Witnesses’ interviews reveal that W1 was aware of R1’s POLST and attempted CPR on R1. Record review indicated that R1 has a POLST in facility file.

Based on interviews and documents review there is an insufficient information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No immediate health and safety hazard is noted during this visit.

Exit interview conducted with WC and a copy of this report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024

LIC9099 (FAS) - (06/04)

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